Choosing Dental Care

By Shirley Gutkowski, RDH, BSDH | July 21, 2006 12:00 am

For years you’ve visited the same dental office for your regular cleanings and the occasional cavity. You’ve had few complaints about your care — certainly none big enough to merit changing dentists. But recently you’ve moved, or your dentist has retired, or your insurance plan has changed, and you’re obliged to make a switch. You know that finding a good dental team is important, so how do you begin the search? What do you look for in a dentist and dental hygienist?

Obviously, the practitioners’ skills and the safety precautions and technology employed in the office are important criteria. Then there are practical considerations, such as the proximity of the office to your home or workplace, the office hours, accepted insurance plans, fees, payment policy, and ability to accommodate emergencies. A comfortable office environment also matters, particularly if you have any anxiety about dental work. You want a dental team with a good “chairside manner,” one that is willing to listen to your concerns, answer your questions, and explain what they’re doing and why.

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Few of these details can be found by flipping through listings for dentists in the phone book. Finding the right dental-care provider will take some time and research, and it is best done under nonemergency conditions. Start your search well before you’re due for a checkup. Often, people look to neighbors, relatives, or other health-care providers for recommendations or referrals. Personal recommendations are a good starting point for finding out about a dentist’s general approach, the demeanor of the office staff, and the reputation of the practice in the community. Once you have some names, you can do your own research to form an opinion.

Background information

A dentist’s technical skills are of utmost importance, but evaluating these skills is not always easy for someone who is not a dental professional. One sign of professional commitment, however, is membership in a professional dental organization such as the American Dental Association (ADA) or a state dental association. The dentist’s receptionist should be able to tell you over the telephone if the dentist maintains such a membership.

When you call a dentist’s office, it’s perfectly all right to ask the receptionist his or her name and how long he or she has worked with the dentist. Does the receptionist sound professional and courteous? Does he or she seem proud of and knowledgeable about the practice? If the dentist treats his staff well and his dentistry is of high caliber, employees tend to brag a little, which is usually a good sign. Any reluctance on the part of the staff to answer your questions, on the other hand, is a worrisome sign.

When you visit an office, take a look around. Dentists who are proud of their work may display “before and after” photos in a photo album or on the walls in the reception area. You can sometimes tell if the dentist’s work is not just cosmetically admirable but also technically sound by looking at the gums in the “after” photos. Healthy gums are pale pink, not bright red. A conscientious dentist will not do cosmetic work if a person’s gums are in poor condition. If the gums look unhealthy in the “after” photo, it should raise a red flag in your mind.

The comprehensive oral exam

Your first appointment with a new dentist should be a comprehensive oral exam, an in-depth screening that enables the dentist to complete your dental records and develop a treatment plan for you. This is a good time to evaluate a dentist’s manner and care and to make sure that this office is right for you. Take note of the equipment used, too. A dentist who relies on older techniques can provide excellent care, but newer technology, some of which is described in this article, can make checkups faster, less painful, and more thorough.

To begin with, the dentist should take your medical and dental history, recording information about your previous dental work, any medical conditions or illnesses you have (or had), medicines you currently take, and allergies you have. (If you have an allergy to latex, mention it when you make the appointment so the office can prepare for your visit.) It’s important that you state how long you have had diabetes, how you control it, and any problems or difficulties you have had recently. The dentist or dental hygienist should follow up on these questions at every visit.

Before any instruments are lifted from the tray, you should be offered a preprocedural rinse with an antimicrobial mouthwash. This is a simple precaution that lowers the bacteria count in the mouth and in the spray generated by rotary tools by over 98%, protecting the dental staff as well as the patient. Anyone treating you should wear gloves, a jacket, eye covering, and a face mask at all times.

The comprehensive oral exam includes a periodontal health screening, a full-mouth series of x-rays, dental photographs, an oral cancer screening, and possibly impressions of your bite to build a model of your teeth. (A comprehensive exam should be scheduled every five years or so, whether or not you have a new dentist.)

The full-mouth series of x-rays, or radiographs, taken during the comprehensive exam is important to detect problems such as tumors or abscesses (chronic and potentially harmful infections) at the roots of the teeth. People with diabetes are prone to dental abscesses, which, contrary to popular belief, are not always painful and may not be noticed until the most advanced stages. A full-mouth set of x-rays includes between 14 and 20 separate pictures. A set of bite-wing
x-rays, which are taken yearly, consists of four films; these detect decay between the teeth but do not show the root ends where abscesses form.

Many people are concerned about the potential health consequences of getting regular x-rays, but the radiation exposure from dental x-rays is minimal, and the health problems that could arise from not having the x-rays are much more dangerous. A lead apron and collar should always be used during x-rays, of course. Pregnant women may wish to postpone the procedure, but today’s high-speed x-ray film is extremely sensitive, resulting in a much quicker exposure time and a substantial decrease in radiation. If the dentist uses digital x-rays, the amount of radiation to which you are exposed is a fraction of the amount used for regular x-ray film.

Another critical part of the comprehensive oral exam is the intra- and extraoral cancer screening. (A cancer screening should also be performed at each cleaning appointment.) The reason oral cancer has such a dismal five-year survival rate (57%) is that 60% of oral cancers are identified late, when the cancer has already advanced to another area. The potentially life-saving screening procedure involves a visual inspection and gentle physical assessment of the jaw, lips, salivary glands, lymph nodes, tongue, and inside tissues of the mouth for any unusual spots, lumps, or lesions.

There are also some excellent tools for detecting oral cancer early. One is the ViziLite, a disposable, handheld light whose wavelength is absorbed by healthy tissue but reflected by abnormal tissue. After you rinse with a special solution, the office lights are dimmed, and the dentist examines your mouth with the ViziLite. Bright white spots indicate potential lesions. To confirm suspected lesions, the dentist or dental hygienist can take what’s called a brush biopsy, in which a stiff brush is used to obtain a sample of cells that is placed on a microscope slide and shipped to a lab. Results are faxed to the dental office in about 48 hours.

During the comprehensive exam, your teeth will be checked for stains, cracks, malformations, and cavities. Some dentists use an intraoral video, a camera that allows you to see your teeth and gums from the dentist’s point of view. This device helps you to see your trouble spots and understand the preventive care the dentist recommends.

Another tool that your dentist may use is a laser-assisted cavity detection device called the DIAGNOdent. Lasers in dentistry are still controversial, and refining the technology is an ongoing task. However, the DIAGNOdent has rapidly gained favor as a tool for detecting decay in the pits and fissures of the back teeth. This laser does not cut or cauterize; it uses a technique called laser fluorescence to measure the density of the enamel. The device translates the degree of decay at each point into a numerical value.

Many dentists still use a handheld metal instrument called an explorer to detect decay by probing the enamel for sticky or soft areas. However, there is a great deal of variation in results among clinicians who use this instrument. Depending on the amount of pressure applied and on the sharpness of the explorer, mechanical probing yields different interpretations. A dentist with a sharper explorer might recommend filling a tooth, while another would decide to watch it for a while. The DIAGNOdent laser eliminates discrepancies among clinicians and enables a dentist to make better decisions about how to proceed with a problem tooth.

Treatment options

In its early stages, tooth decay can be reversed. If the dentist decides an area can be watched, a patient can help remineralize the area by using a combination of fluoride, chewing gum containing xylitol or Recaldent, antibacterial mouthwash, and, of course, diligent plaque removal through brushing and flossing. This is called remineralization therapy.

If tooth decay is more advanced and cannot be reversed, dentists have a variety of options for restoring teeth. There has been some controversy over the use of amalgams, or silver fillings, because they contain a small amount of mercury. While the ADA and the U.S. Food and Drug Administration have found no evidence that amalgams are harmful, some people prefer other filling materials, such as composites of plastic and glass. Composite fillings have been proven over time to be as successful and durable as the standard amalgams, but placing them requires a different technique. If your dentist uses only amalgam, it may mean that he does not feel comfortable using composite materials.

Choosing a dental hygienist

In addition to needing a good dentist, you also need a good hygienist. Ideally, your preferred dentist and dental hygienist work together, making it easy for you to have one-stop oral health care. Sometimes, however, a dentist employs a hygienist who doesn’t share the dentist’s level of patient care, or a hygienist delivers outstanding care while the dentist is less attentive. While it’s unusual, some people have their dental needs provided for by two offices.

In most states, dental hygienists work under the supervision of a dentist. Their relationship is similar to that of a pharmacist and medical doctor. The dentist must personally examine new patients, and only he can prescribe dental x-rays and dental hygiene services, but the dental hygienist is also a licensed practitioner. Like the dentist, the hygienist has had extensive education, passed national and regional board exams, and met the requirements for state licensure. (Most states also require a certain amount of continuing education to maintain licensure.)

When looking for a hygienist, the telephone is a good place to start. Ask the receptionist when the hygienist’s last continuing education course was taken, or talk to the hygienist directly. How long has he or she been in practice? Is he or she a member of the American Dental Hygienists’ Association or the state professional association?

A dental hygienist’s focus is the prevention of oral disease and the treatment of periodontal disease. A good hygienist listens carefully to your concerns and does a thorough job. Getting in and out of the office quickly is not always in your best interest; on the other hand, a hygienist who takes forever at each visit isn’t providing ideal service either.

Professional cleaning is the dental hygienist’s job. The hygienist should also perform a follow-up periodontal health screening to check for gum disease at each visit. The cleaning usually involves scraping hard deposits from the teeth, polishing them (although this is an optional, cosmetic service), and applying a fluoride treatment to prevent decay. Probing depths, a measure of the bone structure supporting the teeth that is taken by sliding a probe into the pocket around the tooth, should be recorded yearly. If you’re not sure what the hygienist is doing or why, ask about it.

If x-rays are taken, asking to see them can help you judge the quality of your care. Unless your teeth are malaligned in your jaw, the radiographs should show perfectly proportional teeth. An x-ray in which the appearance of the teeth is distorted cannot give the clinician good diagnostic information; retakes are sometimes necessary.

Make note of the technology the hygienist employs. Hygienists who rely only on hand instruments may not be doing all they can for their patients. Ultrasonic scalers, for instance, are an improvement over mechanical scalers because they not only remove hard deposits and stains but also kill bacteria and create a soothing sensation on the gums.

Dental anxiety

It doesn’t matter how talented a dental team is if you are afraid to visit their office. Over the years, dental practices have taken strides to reverse their unfortunate reputation as places of torture. Slogans like “We Cater to Cowards” or “Gentle Dental Care” fill the Yellow Pages, and some dental practices seem more like spas than medical offices. Low lighting, soothing aromas, and hot towels can be a boon to those who have learned to fear the dentist office. If you tend to avoid the dentist out of fear, ask how dental anxiety is handled during your initial phone call.

Some practices offer step-by-step desensitizing sessions, in which the first few visits don’t involve going into the treatment room, and the anxiety is gradually overcome. If a dentist will only provide barbiturates or nitrous oxide sedation for anxiety, however, keep calling around. While drugs are extremely effective at decreasing anxiety, and for some people, prescription drugs should be used at every visit, a good dentist and dental hygienist team should have a plan to try relaxing a nervous patient before offering pharmaceuticals. For people who have an overwhelming fear of the dentist, oral care can be accomplished in a hospital under general anesthesia. (Some dentists do general anesthesia in their offices, but it is not yet a recognized dental specialty.)

If a fear of needles makes you dread tooth repair, ask if the dentist uses an advanced anesthetic delivery system called the Wand. This tool electronically delivers the anesthetic so that it reaches and numbs the tissue ahead of the needle and delivers the dose at a slow, steady rate. This makes the procedure longer but virtually pain-free, even on sensitive places such as the roof of the mouth.

For most people, low-level anxiety can be overcome before they leave home or in the dentist’s chair by learning some simple relaxation techniques such as deep-breathing exercises. Some people may prefer a practice that provides virtual reality glasses or ceiling TV screens for distraction; others find it relaxing to bring their own music in an mp3 or CD player and headphones.

Diabetes and dental care

Finding excellent oral health care and a comfortable office environment is especially important for people with diabetes, who are at increased risk for gum disease, dental abscesses, and oral thrush (a fungal infection that forms white, sore patches inside the mouth). Diabetes can make any infection slower to heal; at the same time, the presence of an infection such as gum disease can raise one’s blood glucose level, making diabetes harder to control. Oral surgery and dental anxiety can also upset blood glucose control.

Because of the interaction of diabetes and periodontal disease, people with diabetes may require dental visits as often as four times a year. When searching for an oral-health-care provider, ask about a dentist’s or hygienist’s experience in treating people with diabetes. Are steps taken to keep invasive procedures as short and stress-free as possible? Is the dentist willing to wait until a person’s diabetes is under control to begin nonemergency treatment?

In general, the morning is thought to be the best time for people with diabetes to have routine dental appointments, because their blood sugar level should be closest to normal after the morning meal and medicine. Inform your dentist and hygienist at each visit how well your diabetes is being controlled and if there have been any changes in your condition or medicines since your last visit. Check your blood glucose level before the appointment and, if your stress level is high or the procedure is prolonged, during it as well. If periodontal surgery is necessary, have your physician and dentist discuss the procedure together.

Getting it right

As you can see, there’s a lot to think about when choosing a dentist and dental hygienist. If you do your research now, though, these valuable members of your health-care team can save you a great deal of pain and problems in the future. Keep searching until you find an office you trust, and be sure to keep up with your home dental care while you’re looking.

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